|Year : 2021 | Volume
| Issue : 1 | Page : 6-9
The Urological Society of India Guidelines for the management of urethral stricture (Executive Summary)
Sanjay B Kulkarni1, Amilal Bhat2, Hardev S Bhatyal3, Gyanendra R Sharma4, Deepak D Dubey5, Nikhil Khattar6, Arabind Panda7, Anujdeep Dangi8, Vikram Shah Batra1, Pankaj M Joshi1
1 Kulkarni Reconstructive Urology Center, Pune, Maharashtra, India
2 Bhat's Hypospadias and Reconstructive Urology Hospital and Research Centre, Jaipur, Rajasthan, India
3 Department of Peadiatric Urology, BLK Superspeciality Hospital, New Delhi, India
4 Department of Reconstructive Urology, Chitale Clinic Pvt. Ltd., Sholapur, Maharashtra, India
5 Department of Urology, Manipal Hospitals, Bengaluru, India
6 Department of Urology, Medanta - The Medicity, Gurugram, Haryana, India
7 Department of Urology, KIMS Hospitals, Secunderabad, Telangana, India
8 Department of Reconstructive Urology, Christian Medical College and Hospital, Vellore, Tamilnadu, India
|Date of Web Publication||1-Jan-2021|
Pankaj M Joshi
Kulkarni Reconstructive Urology Center, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kulkarni SB, Bhat A, Bhatyal HS, Sharma GR, Dubey DD, Khattar N, Panda A, Dangi A, Batra VS, Joshi PM. The Urological Society of India Guidelines for the management of urethral stricture (Executive Summary). Indian J Urol 2021;37:6-9
|How to cite this URL:|
Kulkarni SB, Bhat A, Bhatyal HS, Sharma GR, Dubey DD, Khattar N, Panda A, Dangi A, Batra VS, Joshi PM. The Urological Society of India Guidelines for the management of urethral stricture (Executive Summary). Indian J Urol [serial online] 2021 [cited 2021 May 12];37:6-9. Available from: https://www.indianjurol.com/text.asp?2021/37/1/6/306050
These guidelines have been drafted by the Urological Society of India (USI) urethral stricture guidelines panel for the use of urologists. The recommendations are updated till August 2020 and will remain valid till the next update or a maximum period of 5 years. This executive statement represents the best evidence and expert opinion and are not intended to replace clinical judgement. The complete guidelines document can be accessed from the USI website at www.usi.org.in.
| Methodology|| |
The majority of evidence for the management of urethral stricture is from retrospective case series. Randomized controlled trials for urethral reconstructive procedures are rare. The panel recognizes that certain aspects of urethral reconstructive surgery present unique challenges for randomized trials.
Literature search was conducted on PubMed, Cochrane Central Register of Controlled Trials, Embase, Mendeley, and Directory of Open Access Journals. The available articles were reviewed by the panelists and evidence was extracted. The articles published from India and pertaining to the Asian subpopulation were analyzed along with the world literature. Levels of evidence (LE) was based on the Centre for Evidence-Based Medicine guidelines.
| Recommendations|| |
The guidelines panel based its final recommendations on the best available Indian data and global evidence.
Grades of recommendation (GR) (strong/moderate/weak) are the strength of mandate based on the extent of risk-benefit ratio of either taking or not taking an action. The Clinical Principle is a statement that is widely agreed upon by clinicians, for which there may or may not be evidence in the medical literature. An Expert Opinion is a statement agreed on by the guidelines panel in the absence of evidence. In atypical circumstances, the clinician should carefully consider the benefits, risks, and patient preferences carefully before arriving at a decision.
The burden of urethral stricture disease in India has not been reported, but the etiology patterns have been reported in limited studies from men undergoing urethroplasty. A study of over 400 patients in eastern India has reported iatrogenic injury as the most frequent cause. Urethral catheterization was a more frequent cause than transurethral surgery in this population. A study comparing characteristics of strictures in men undergoing urethroplasty at leading centers in India and the West suggested that trauma-related strictures were much more common in India (36% vs. 15.8%), whereas the iatrogenic were lesser (16% vs. 35%). The incidence of Lichen Sclerosus (LS)-associated strictures were three times as compared to the western data (21.5% vs. 6.9%). Similarly, the number of pan-urethral strictures were almost two times that in West (18% vs. 8.9%), whereas strictures involving only the penile urethra were four times less common (5.3% vs. 27%). Regarding iatrogenic strictures, post-transurethral resection of prostate (TURP) strictures were three times more common than in the Western population.
The unique socioeconomic condition and the lack of easily accessible health care results in late presentations. Widespread tobacco chewing and abuse is a unique problem to the Indian subcontinent and certain other developing countries. Panurethral and long strictures are more common The long-term outcomes of buccal mucosal graft in this population are inferior as compared to nonusers as was reported in two Indian studies, whereas the outcomes with lingual mucosa remain unaffected by tobacco.
| Guideline Statements|| |
Meatal/fossa navicularis strictures,
- Meatal dilatation is palliative (LE-4, GR moderate)
- Meatotomy (Ventral) is the first line of treatment when possible (LE-4, GR moderate)
- Meatoplasty can be performed with dorsal inlay Buccal Mucosa graft as first choice (LE-4, GR moderate)
- Ventral preputial skin graft as alternative (LE-5, GR-strong)
- Local skin flaps can be used for meatoplasty (LE-4, GR moderate).
- Urethral dilatation Is palliative. It can be offered in a patient unfit for surgery, refuses surgery or after multiple failed surgeries (LE-3, GR-Moderate)
- Dilatation/direct visual internal urethrotomy (DVIU) in penile strictures has poor results and best avoided (LE-3, GR-strong)
- Self-catheterization: Palliative, noncurative (LE-3, GR-strong)
- Non-lichen sclerosus
- Buccal mucosa urethroplasty dorsal onlay/inlay (LE-2, GR-strong)
- Local flap (LE2, GR-moderate)
- Narrow urethra; two staged urethroplasty (LE-3, GR-moderate).
- Single staged buccal mucosa (LE-3, GR-strong).
Nontraumatic bulbar strictures
- DVIU (LE3, GR-strong)
There is not enough evidence to recommend Self-calibration after DVIU for preventing re-stricture (LE-3, GR-strong)
- Site of graft does not alter the outcomes for bulbar urethroplasty (LE-3, GR-strong)
- In obese patients, young sexually active and post-TURP proximal bulbar strictures ventral onlay urethroplasty remains the first-choice (LE-5, clinical principle)
- Proximal bulbar strictures with healthy, spongiosa ventral onlay urethroplasty is the first choice procedure (LE5, clinical principle)
- Dorsal approaches include Barbagli-Circumferential mobilization or Kulkarni-One side dissection for dorsal onlay and Asopa for Dorsal inlay
- Non-transecting bulbar urethroplasty. Incise dorsally and assess urethral plate. Short stricture, ventral mucosa can be excised and stricturoplasty performed (LE3, GR moderate).
Traumatic bulbar strictures
- There is no role for DVIU (LE-3, GR-strong)
- Short stricture-excision with anastomotic urethroplasty (LE-3, GR strong)
- Long stricture/failed anastomotic -Augmented anastomotic urethroplasty is recommended (LE 4, GR strong).
- Simple urethral dilatation is palliative in nature (LE-4, GR-moderate)
- Internal urethrotomy has no role (LE-3, GR-strong)
- One-sided dissection is the best option (LE-3, GR-strong)
- Two-stage urethroplasty (Johannsson's in the first stage with/without dorsal inlay Buccal Mucosal augmentation) can be performed in obliterative strictures. (LE-4 GR-moderate)
- Non lichen Sclerosus–Fascio cutaneous genital flaps can be performed (LE-3, GR-moderate)
- Perineal Urethrostomy–Salvage procedure (LE-4, GR-moderate).
Pelvic fracture urethral distraction defects,
- Immediate Suprapubic Catheter (SPC) with delayed urethroplasty is the standard of care (LE-3, GR-strong)
- Primary endoscopic realignment in stable patients is an option (LE-3, GR-weak)
- Anastomotic Urethroplasty with simple/elaborated perineal approach should be performed LE-3, GR-strong
- Adequate scar excision, optimal crural separation and inferior Pubectomy, tension free bulbo membranous anastomosis should be performed
- Supracrural rerouting only if indicated
- Perineo-abdominal repair with omental wrap may be required for complex cases (LE-3, GR-strong)
- Children, recto urethral fistula and complex urethroplasties should be managed with help from experts (LE-3, GR-strong)
- Bulbar Urethral necrosis: Pedicled Preputial or penile skin tube is the procedure of first choice (LE-3, GR-moderate)
- Rectourethral fistula approach can be perineal/abdominal perineal with tissue interposition: Omentum, Dartos pedicle flap, Gracilis can be used as interposition (LE-3 GR-strong); diverting colostomy and SPC is recommended (LE 4, GR moderate).
Dilatation/direct visual internal urethrotomy,
- Laser and cold knife–results are equivalent (LE2, GR-strong)
- Catheter removal should be within 72 h. Long-term catheterization has no role (LE 4, GR-moderate)
- Intraurethral injection of Mitomycin/other adjuvant agents are not recommended at present (LE-4, GR-weak).
Bladder neck contracture (post-transurethral resection of prostate/post-radical prostatectomy),
- Urethral dilatation is a treatment option in post-radical prostatectomy vesicourethral stenosis (LE-3, GR-moderate)
- Endoscopic bladder neck incisions are the initial procedure of choice (LE-3, GR-moderate)
- Intralesional injection of mitomycin/steroids can be tried in recurrent cases (LE-4, GR-moderate)
- Open/Robotic Y-V plasty and its modifications along with end to end anastomosis are indicated for recalcitrant vesicourethral stenosis and bladder neck contracture (LE-4, GR moderate).
Post-transurethral resection of prostate proximal bulbar strictures,
Ventral onlay buccal graft augmentation is the procedure of choice in proximal strictures close to the membranous urethra (LE-3, GR strong).
Female urethral strictures,
- A single dilatation of a short segment stricture may be attempted. It is rarely curative (LE-3, GR strong)
- Regular dilatations in females with lower urinary tract symptoms without a proven stricture on endoscopy has no proven benefits (LE-4, GR strong)
- Urethroplasty (onlay or inlay) can be offered when dilatation fails-Vaginal and buccal mucosa both are acceptable options (LE-4, GR strong)
- Local flap urethroplasty is a feasible option for strictures involving distal urethra (LE-4, GR moderate).
- Results are guarded (LE-4, GR-moderate)
- Surgical options include anastomotic urethroplasty, flaps or free graft augmentation. (LE3, GR moderate)
- Flaps recommended over free grafts (LE-5, GR moderate)
- Perineal urethrostomy/scrotal drop back are salvage procedures (LE-4, GR weak).
Post-hypospadias surgery urethral strictures,
- Bulbar strictures:
Excision and primary anastomosis is not recommended. (LE-5, GR strong).
- Penile stricture:
- Dorsal inlay Buccal/Penile skin graft augmentation urethroplasty is the procedure of choice (LE-5, GR weak)
- Johannsson's Stage I with Asopa dorsal buccal inlay and tubularization in the second stage is an option (narrow/deficient urethral plate) (LE 3, GR moderate)
- Two staged buccal urethroplasty (Insert buccal in the first stage and tabularization after 6 months. Inform patients about graft contraction and possible need for redo grafting (LE5, GR weak).
- Fossa navicularis/meatal stenosis:
- Single dilatation (LE4, GR moderate)
- Dorsal inlay Buccal/nonhair bearing skin graft augmentation (LE-4, GR moderate).
Chronic renal failure and strictures (pre/post-transplant)
- Urethroplasty is recommended before performing renal transplant (LE4, GR weak)
- The complication rates of urethroplasty are higher in patients on dialysis awaiting renal transplantation (LE4, GR moderate)
- Urethral reconstruction after renal transplantation has been seen to be safe. (LE4, GR moderate).
Neurogenic bladder and Clean Intermittent Catheterization
Patients who are on Clean Intermittent Catheterization and develop stricture urethra can be offered urethroplasty (LE-4, GR moderate).
- Not recommended (LE3, GR strong)
- Stent failures should be treated by urethroplasty, removal of stent and preferably dorsal approach (LE-3, GR strong).
- Catheter removal at 3 weeks if performing peri-catheter urethrogram and at 4 weeks if peri-catheter urethrogram is not performed (LE4, GR moderate)
- For complex cases the catheter is removed at 6 weeks (LE-4, GR moderate).
- Uroflow >12 ml/s after a urethroplasty as optimal (LE-3, GR moderate) Follow with Uroflow, Patient-reported outcome measure at 3, 6, 9 and 12 months and yearly long term follow-up (LE-2, GR strong).
- Unsuitable Buccal Mucosa-Chronic tobacco exposure. The usual next choice of material is the lingual mucosa/preputial skin (In non-lichen Sclerosus) (LE3, GR moderate). Other experimental options are Saphenous vein (LE3, GR moderate) or tunica albuginea, rectal mucosa, tissue engineering (LE4, GR moderate).
| References|| |
Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, et al
. Rating quality of evidence and strength of recommendations: Going from evidence to recommendations. Br Med J 2008;336:
Singh J, Priyadarshi V, Pandey P et al
.Urethral stricture etiology revisited: An Indian scenario. Uro Today Int. J 2013 February 6 (1) : art 5.
Stein DM, Thum DJ, Barbagli G, Kulkarni S, Sansalone S, Pardeshi A, et al
. A geographic analysis of male urethral stricture aetiology and location. BJU Int 2013;112:830-4.
Yalcinkaya F, Zengin K, Sertcelik N, Yigitbasi O, Bozkurt H, Sarikaya T, et al
. Dorsal onlay buccal mucosal graft urethroplasty in the treatment of urethral strictures-does the stricture length affect success? Adv Clin Exp Med 2015;24:297-300.
Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, et al
. Tobacco use in 3 billion individuals from 16 countries: An analysis of nationally representative cross-sectional household surveys. Lancet 2012;380:668-79.
Morey AF, Lin HC, DeRosa CA, Griffith BC. Fossa navicularis reconstruction: impact of stricture length on outcomes and assessment of extended meatotomy (first stage Johanson) maneuver. J Urol 2007;177:184-7.
Zumstein V, Dahlem R, Maurer V, Marks P, Kluth LA, Rosenbaum CM, et al
. Single-stage buccal mucosal graft urethroplasty for meatal stenoses and fossa navicularis strictures: A monocentric outcome analysis and literature review on alternative treatment options. World J Urol 2020;38:2609-20.
Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty. J Urol 1996;155:123-6.
Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided anterior urethroplasty: A new dorsal onlay graft technique. BJU Int 2009;104:1150-5.
Asopa HS, Garg M, Singhal GG, Singh L, Asopa J, Nischal A. Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach. Urology 2001;58:657-9.
Andrich DE, Mundy AR. Non-transecting anastomotic bulbar urethroplasty: A preliminary report. BJU Int 2012;109:1090-4.
Guralnick ML, Webster GD. The augmented anastomotic urethroplasty: Indications and outcome in 29 patients. J Urol 2001;165:1496-501.
Joshi P, Kaya C, Kulkarni S. Approach to bulbar urethral strictures: Which technique and when? Turk J Urol 2016;42:53-9.
Kulkarni SB, Joshi PM, Venkatesan K. Management of panurethral stricture disease in India. J Urol 2012;188:824-30.
Spencer J, Blakely S, Daugherty M, Angulo JC, Martins F, Venkatesan K, et al
. Clinical and patient-reported outcomes of 1-sided anterior urethroplasty for long-segment or panurethral strictures. Urology 2018;111:208-13.
Johnsen NV, Moses RA, Elliott SP, Vanni AJ, Baradaran N, Greear G, et al
. Multicenter analysis of posterior urethroplasty complexity and outcomes following pelvic fracture urethral injury. World J Urol 2020;38:1073-9.
Kulkarni SB, Orabi H, Kavanagh A, Joshi PM. RE Re Do urethroplasty after multiple failed surgeries of pelvic fracture urethral injury. World J Urol 2019;10.1007. s00345-019-02917-1
Mundy AR. Adjuncts to visual internal urethrotomy to reduce the recurrence rate of anterior urethral strictures. Eur Urol 2007;51:1467-8.
Mazdak H, Izadpanahi MH, Ghalamkari A, Kabiri M, Khorrami MH, Nouri-Mahdavi K, et al
. Internal urethrotomy and intraurethral submucosal injection of triamcinolone in short bulbar urethral strictures. Int Urol Nephrol 2010;42:565-8.
Ramchandani P, Banner MP, Berlin JW, Dannenbaum MS, Wein AJ. Vesicourethral anastomotic strictures after radical prostatectomy: Efficacy of transurethral balloon dilation. Radiology 1994;193:345-9.
Park R, Martin S, Goldberg JD, Lepor H. Anastomotic strictures following radical prostatectomy: Insights into incidence, effectiveness of intervention, effect on continence, and factors predisposing to occurrence. Urology 2001;57:742-6.
Kulkarni SB, Joglekar O, Alkandari M, Joshi PM. Management of post TURP strictures. World J Urol 2019;37:589-94.
Barbagli G, Kulkarni SB, Joshi PM, Nikolavsky D, Montorsi F, Sansalone S, et al
. Repair of sphincter urethral strictures preserving urinary continence: Surgical technique and outcomes. World J Urol 2019;37:2473-9.
Lane GI, Smith AL, Stambakio H, Lin G, Al Hussein Alawamlh O, Anger JT, et al
. Treatment of urethral stricture disease in women: A multi-institutional collaborative project from the SUFU research network. Neurourol Urodyn 2020; 10.1002/nau. 244507
Osman NI, Mangera A, Chapple CR. A systematic review of surgical techniques used in the treatment of female urethral stricture. Eur Urol 2013;64:965-73.
Hofer MD, Gonzalez CM. Management of radiation-induced urethral strictures. Transl Androl Urol 2015;4:66-71.
Rosenbaum CM, Engel O, Fisch M, Kluth LA. Urethral stricture after radiation therapy. Urologe A 2017;56:306-12.
Joshi PM, Barbagli G, Batra V, Surana S, Hamouda A, Sansalone A, et al
. A novel composite two-stage urethroplasty for complex penile strictures: A multicentre experience. Indian J Urol 2017;33:155-8.
] [Full text]
Talab SS, Cambareri GM, Hanna MK. Outcome of surgical management of urethral stricture following hypospadias repair. J Pediatr Urol 2019;15:354.
Meeks JJ, Gonzalez CM. Urethroplasty in patients with kidney and pancreas transplants. J Urol 2008;180:1417-20.
Casey JT, Erickson BA, Navai N, Zhao LC, Meeks JJ, Gonzalez CM. Urethral reconstruction in patients with neurogenic bladder dysfunction. J Urol 2008;180:197-200.
Angulo JC, Pankaj J, Arance I, Kulkarni S. Urethral reconstruction in patients previously treated with Memokath™ urethral endoprosthesis. Reconstrucción uretral en pacientes previamente tratados con endoprótesis uretral Memokath™. Actas Urol Esp 2019;43:26-31.
Sussman RD, Hill FC, Koch GE, Patel V, Venkatesan K. Novel pericatheter retrograde urethrogram technique is a viable method for postoperative urethroplasty imaging. Int Urol Nephrol 2017;49:2157-65.
Jackson MJ, Chaudhury I, Mangera A, Brett A, Watkin N, Chapple CR, et al
. A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure. Eur Urol 2013;64:777-82.
Rao SN, Khattar N, Akhtar A, Goel H, Varshney A, Sood R. Everted saphenous vein graft for long anterior urethral strictures in men with tobacco-exposed oral mucosa: A prospective nonrandomized study. Indian J Urol 2019;35:134-40.
] [Full text]